Wound treatments Flashcards
Methods of debridement
Selective: Sharp
Autolytic
Enzymatic
Biologic
Non-Selective:
Mechanical
Surgical
Sharps Debridement
Selective
Aggressive
Possible pain
Not appropriate if insufficient vascular supply or poor nutrition.
Sharp debridement termination
Clinician fatigue Excessive pain Decline in status/tolerance Extensive bleeding New fascial plane No more necrotic tissue
Autolytic Debridement
Natural degredation of devitalization
Conservative
Little pain
Slow
Not appropriate with infection or arterial insufficiency
Enzymatic debridement
Use of enzymatic ointments to loosen and remove devitalized tissue and protein
Papain-Urea Collagenase Sometimes slow Non-selective May be painful
Enzymatic Debridement procedure and termination
Termination: failure to decrease necrosis or necrosis resolve.
Procedure: prescription needed.
cross-hatch first.
moist environment
Biologic debridement
Larva: sterile, lab-raised maggots.
Requires 2* dressing.
Selective
Can reduce bacteria
Seldom used in US
Mechanical Debridement
External force to non-selectively remove necrotic tissue
Painful
Can cause bleeding
Gauze, pulse lavage, whirlpool, wet to dry
Surgical Debridement
Physician: extensive exploration of wound bed and deep debridement
For: ascending cellulitis, osteomyelitis, undermining
Necrotic tissue near vital organs
Goals of debridement
Promote wound cleansing to remove debris and necrosis.
Reduce bacterial bioburden/risk of infection.
Promote optimal enviroment for wound healing.
Promote inflammation to facilitate angiogensis.
PT documentation
Must have script Selective vs non Conservative sharps only. Type/amount of necrosis Insturments
Contraindications
Dry gangrene
Intact eschar s drainage, erythema or flatuance or poor circulation
Unidentified structures in wound bed
Whirlpool
Benefits: cleanses wound, promotes circulation, promotes debridement
Precautions: malignancy, promotes edema, can cause trauma to healthy tissue, avoid in diabetic wounds
Whilpool Risks
Infections: contaminated water, cross contamination
Superhydration/maceration
Changing of skin pH
Hydrotherapy considerations
water temp: 80-92, 92-96, 96-104
Dependent position
Duration
Addatives
Pulsatile lavage
Promotes local circulation Reduces bacterial load Healthy debridement if using high pressure jet 5-15 psi. Wear protective clothing
Pulsatile Lavage
Reliable alternative to whirlpool
Minimal risk of cross contamination
Eliminates dependant edema issues
Wound Irrigation
Syringe vs gauze: 35 ml syringe Irrigate with dressing changes Saline Wound cleanser Betadine Hydrogen Peroxide Dakin's Acetic Acid
4-15 psi
Electrotherapy
Increased perfusion Stimulates fibroblasts Increases tensile strength Antibacterial Debridement effects Migration of inflammatory and repair cells
Current of injury
Electrical potential across skin
Current disappears with regeneration of tissue.
Positive polarity: coagulation of protein, hardening of tissue, coagulation of blood, enhancing scar formation
Negative polarity: liquefying protein, softening tissue, bactericidal, debridement
US
Stimulates release of chemoattractants by fibroblasts, mast cells, and macrophages.
May stimulate fibroblast proliferation for collagen deposition, angiogensis, and wound contraction.
Increases wound tensile strength.
US contraindications
osteomyelitis active bleeding severe arterial insufficiency acute DVT untreated acute wound
consider poor ability to penetrate eschar
Wound Vac (negative pressure therapy)
Increases perfusion to wound: increases o2 and nutrients
Helps drainage control
Change dressing every 48 hrs
Decreased edema, increased blood flow, decreased bacteria, more granulation tissue, promotes epithelialization
npwt indications
Arterial, venous, pressure, mixed vascualr ulcers, dehisced surgical wounds, wounds with tunneling/undermining, assist flap survival
Not indicated for wounds with 20%+ non viable tissue
NPWT contraindication and precaution
Contra: malignancy in wound, untreated osteomyelitis, unexplored fistula, eschar, exposed vessels/organs
Precaution: bleeding, anticoagulants, proximity to vessels, organs, bone, and enteric fistula
MIRE (anodyne)
Photo energy that produces NO in hemoglobin to reoxygenate wound bed.
Vasodilates
Hyperbaric o2
Full body or multiplace 100% o2 at high pressures Daily or BID Promotes angiogenesis and o2 perfusion Restores pH
HBOT indications
Grade 3/4 diabetic ulcer, compromised skin graft, radionecrosis, arterial insufficiency, crush injury, necrotizing fasciitis, gas gangrene, chronic osteomyelitis
Compression
Reduce/control edema Base of toes to knees Distal to proximal ABI greater than .6-.8. Precaution: CHF
Compression classifications
1: 14-18=edema prevention, DVT prophylaxis
2: 18-24: dependent edema
3: 25-35: venous insufficiency
4: 40-50: lymphedema
Bioengineered skin substitutes
Apligraf: cultured from newborn foreskin, replaces dermis and epidermis
Indicated for non-infected venous ulcers
Dont use with bovine alergies
Dermagraft: derived from human fibroblast, replaces dermis only
OASIS
from pig small intestine submucosa
collagenous ECM c cytokines
temporary dressing for partial and full thickness wounds
hydrated on application
Topical growth factors
from recombinant human platelet derived growth factor
expensive
